One cannot but be struck with the fact that in many (if not in most) attacks of acute insanity the patient, on recovery, has no recollection of the incidents of the illness. She may have answered our questions in a way showing that at the time there was not only a consciousness of a certain kind present, but also the capacity for understanding and replying in accordance with her ideas (however unfounded they may, in fact, be), and yet on recovery, or even in a temporary lucid interval, all remembrance of the disordered state has passed away, and that, too, beyond the capacity of recall—nothing but a misty, hazy remembrance of some condition which has been passed through remains, just as one finds it impossible to re-instate the details of a dream, the reality of which was at the time vivid in consciousness. We have here to deal with a dual consciousness, a knowledge of states apparently incompatible with, and distinct from, each other. We are all familiar with states of acute mental disturbance where there is difficulty in making the patient understand what we are saying—not necessarily difficult or involved questions, but simple queries relating to what we think are matters in the patient‘s consciousness, such as it is. Here it is doubtful if the patients really understand what we are saying, though there is no doubt about their hearing the question, e.g., they may hear the question but the reply will be merely the reiteration of some particular delusion which has no connection with the question, or there need not be any reply at all, as if we were addressing them in a foreign language which they did not understand, or as if what is said to them has a different meaning from what is intended.

Few subjects of late years have so much engaged public attention as the care and treatment of the mentally infirm, and the pen of almost every writer and critic has been busy over this topic.

The mere accumulation of facts is useless unless some attempt is made to interpret their significance; therefore in this paper I propose to examine my observations on blood-pressure with the design of seeing whether its routine estimation in the insane is worth while; whether from it any fairly trustworthy conclusions can be drawn as to the condition of the circulatory apparatus during life, or as to the prognosis, not only with reference to the mental disorder, but as to the prospects of the duration of life, or whether the time spent in this direction might not more profitably be otherwise employed; and further, to ascertain whether the results obtained tally with those of previous workers.

The discovery by Schaudinn of the Spirochæta pallida was the starting-point of an extensive series of investigations which have thrown much light on the nature of syphilitic infection and its consequences. Reliable authorities are agreed as to the aetiological relationship between this organism and syphilitic disease, and its presence can with ease be demonstrated in chancres, syphilides, and the tissues of cases of congenital syphilis. In tertiary lesions its presence has been noted in gummata and in aortitis, though only in a very few cases. In the so-called para-syphilitic diseases it has not yet been seen. If it be the case that the presence of the organism be indispensable to the production of tertiary and para-syphilitic lesions, the difficulty of demonstrating it may be due to one or both of the following causes: (1) The organisms may be present in another form representing a different stage in their life cycle; or (2) they may be so few in number as to render demonstration extremely difficult, as is the case with the tubercle bacillus in the lesions of chronic fibroid phthisis. The difficulty consequent on a paucity in numbers may be enhanced by difficulty in staining. Two methods of staining the spirochete are in use–Giemsa's stain for film preparations, and a silver impregnation method for the examination of tissues. It is a remarkable fact that tissue which shows enormous numbers of silver impregnated organisms may show very few or none at all in the films stained by Giemsa's method, while on the other hand we have noted an extreme variability in the extent to which impregnation by silver may be obtained; for example, if the tissues of a syphilitic infant be fixed soon after death and while still in a very fresh state, impregnation may be very slight in some parts and distinct in others; thus, in the case of a syphilitic pneumonia, the organisms in the fresh proliferating pneumonic tissue are not seen, or are represented by delicate spirals which are recognised with difficulty, while in the desquamating and degenerating epithelium of the bronchi they may be much more distinct. It is, on the other hand, a striking fact that the spirochaetes in a syphilitic fætus which has been dead for some time are usually impregnated easily with silver, and this is in accord with other observations in the use of the silver impregnation method in demonstrating structures.

This research was carried on in the laboratory at Horton Asylum, and was directed to that vexed question as to whether the Bacillus paralyticans (which Dr. Ford Robertson has described) was the cause of general paralysis of the insane or not.

Let me first explain or define the terms used in the title of this paper. By “hospital treatment” I mean treatment in any institution where patients have to be treated in numbers together, and where it is possible to have efficient nursing. My remarks, however, will have special reference to county and borough asylums as they exist at present. By the “acutely insane” I mean those patients who are suffering from insanity which has begun at a recent date, and which we may hope to relieve.

The enormous importance of the disease under consideration is, I am sure, not adequately realised, and it is for this reason that I am particularly desirous of bringing the subject to the notice of members of the Medico-Psychological Association. In my opinion the status lymphaticus constitutes one of the most serious problems of medical science at the present time, especially in these days of deaths under anæsthetics.

When the Australasian Medical Congress met in Melbourne, in 1889, I dealt with “The Housing of the Insane in Victoria, with Special Relation to the Boarding-out System of Treatment.” Since then I have had ample opportunity of satisfying myself that such a method of caring for and treating the harmless insane is not suited to our colonial life. Much personal attention was given to this matter, and I was not satisfied with the results, the majority of the patients being in the care of officials of the various hospitals practically as servants. This was given a trial, as the official staff were practically the only applicants, not that I believed in the advisability of granting them patients. I ceased doing so, because it was evident the cases were taken for what could be got out of them, a circumstance which existed also with other applicants. This method of caring for our accumulated insane population being demonstrated unsuitable, we perforce fell back upon institutional accommodation for the chronic harmless cases.

The use of Receiving Houses, that is to say, houses established specially for the observation of doubtful cases of mental disorder, is almost entirely of Australian origin, although something analogous exists, and has existed for many years in England and Scotland, in the Lunacy Wards attached to the Workhouses, Infirmaries, and Poor Houses. The latter, however, do not fulfil all the uses that the Receiving House can be put to; neither are they independent institutions, nor do the terms for which patients can be received correspond.

One cannot visit the wards of an asylum without realising that there are many types of mental disease, each with its own symptoms and physical signs, and that intercurrent and overlapping affections of the mind are especially common; thus, in maniacal excitement you may find delusions, in paranoia you find delusions with marked impairment of judgment, in general paralysis you get, in addition to physical signs, delusions, which vary from the facility of the early period to the more difficult mentation found in the advanced age, so that here we have three distinct types of disease, each of which may have delusions, and the delusions may all be of the exalted variety— the patients may consider themselves gods, kings, or mighty personages. The progress of research has had more difficulties to contend with in the subject of mind than in almost any other. It is a subject which is intangible, yet its reactions can be timed. It is unseen, yet its force can manifest itself in various ways through various channels, and it is even possible to transfer it from one person to another if the medium is so constituted, as in hypnotism, thought transference, and similar phenomena. It may occur to you to ask why has the subject of insane movement and obsession been chosen for this paper; well, gentlemen, for some years it has been my lot to witness, on my daily round of the wards, grotesque movements, antics and pantomimic display by patients, which, were they not interesting as symptoms and physical signs of nervous disease, might otherwise be depressing because of their meaninglessness. About three years ago, however, I had my attention drawn to a woman who seemed engaged in making movements, the precise character of which I had not read of or seen before in any asylum. I shall show you this patient making these movements by means of the cinematograph. We would have brought her here only she obstinately refuses to operate when watched, and it was necessary to have the cinematograph pictures focussed through a partly open window when she least suspected observation. Gentlemen, we are well acquainted with such terms as insane acts, insane expression, insane language, insane conduct, and insane movements.

To a gathering of physicians, each of whom is actively engaged in the treatment of insanity, it would be both impertinent and needless for me to enlarge upon the present-day position of our knowledge of clinical psychiatry. As you are aware, each new discovery in the laboratory of medical science has been seized upon, elaborated, and applied to the treatment of mental diseases or considered in connection with it. Unfortunately the laboratory workers exercise only too fully the ancient prerogative of doctors to differ, and their observations and the results of their researches are thus vitiated, and further research rendered all the more difficult and needful. If the dawn and full daylight of bacteriological science have impressed us with the all-importance to mankind of the infinitely little, may I be pardoned for stating that at the present time the importance of securing more unanimity of opinion amongst its competent research workers is infinitely great.